Commentary--Project Towards No Drug Abuse: an evidence-based drug abuse prevention program.

Project Towards No Drug Abuse (Project TND) is a research-based program that has been examined over seven group-randomized controlled trials. In all trials, an effect has been found on hard drug use. An effect has been found on alcohol use in four trials, and on cigarettes and marijuana in two trials. (Arguably, an effect is found on marijuana in three trials.) Program effects on violence-related behavior were established in earlier trials, though such effects were not assessed in later trials. Certainly, as in most scientific studies, there are limitations in the interpretation of the effects obtained, particularly regarding cigarette and marijuana use and violence-related behavior, and more empirical work is needed. For Project TND, however, numerous trial replications have been completed, and the effects within each trial could not have been obtained by chance alone more than 10 % of the time (two-tailed). These results suggest that Project TND is indeed evidence-based. To be evidence-based means that evidence has accumulated to suggest that the program is likely to work, at least under conditions that are comparable to those in which it has been tested.

Reducing HIV and partner violence risk among women with criminal justice system involvement: a randomized controlled trial of two motivational interviewing-based interventions.

Women with histories of incarceration show high levels of risk for HIV and intimate partner violence (IPV). This randomized controlled trial with women at risk for HIV who had recent criminal justice system involvement (n = 530) evaluated two interventions based on Motivational Interviewing to reduce either HIV risk or HIV and IPV risk. Baseline and 3, 6, and 9-month follow-up assessments measured unprotected intercourse, needle sharing, and IPV. Generalized estimating equations revealed that the intervention groups had significant decreases in unprotected intercourse and needle sharing, and significantly greater reductions in the odds and incidence rates of unprotected intercourse compared to the control group. No significant differences were found in changes in IPV over time between the HIV and IPV group and the control group. Motivational Interviewing-based HIV prevention interventions delivered by county health department staff appear helpful in reducing HIV risk behavior for this population.

One-year follow-up evaluation of Project Towards No Drug Abuse (TND-4).

OBJECTIVES: This paper describes the one-year outcomes of the fourth experimental trial of Project Towards No Drug Abuse. Two theoretical content components of the program were examined to increase our understanding of the relative contribution of each to the effectiveness of the program. METHODS: High schools in Southern California (n=18) were randomly assigned to one of three conditions: cognitive perception information curriculum, cognitive perception information+behavioral skills curriculum, or standard care (control). The curricula were delivered to high school students (n=2734) by project health educators and regular classroom teachers. Program effectiveness was assessed with both dichotomous and continuous measures of 30-day substance use at baseline and one-year follow-up. RESULTS: Across all program schools, the two different curricula failed to significantly reduce dichotomous measures of substance use (cigarette, alcohol, marijuana, and hard drugs) at one-year follow-up. Both curricula exerted an effect only on the continuous measure of hard drug use, indicating a 42% (p=0.02) reduction in the number of times hard drugs were used in the last 30 days in the program groups relative to the control. CONCLUSIONS: The lack of main effects of the program on dichotomous outcomes was contrary to previous studies. An effect on an ordinal count measure of hard drug use among both intervention conditions replicates previous work and suggests that this program effect may have been due to changes in cognitive misperception of drug use rather than behavioral skill.

The impact of clean indoor air exemptions and preemption policies on the prevalence of a tobacco-specific lung carcinogen among nonsmoking bar and restaurant workers.

OBJECTIVES: We studied the impact of clean indoor air law exemptions and preemption policies on the prevalence of a tobacco-specific lung carcinogen-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)--among nonsmoking bar and restaurant workers. METHODS: secondhand smoke were compared with results from participants who were exposed to it. RESULTS: Participants exposed to workplace secondhand smoke were more likely to have any detectable level of NNAL (P=.005) and higher mean levels of NNAL (P < .001) compared with nonexposed participants. Increased levels of NNAL were also associated with hours of a single workplace exposure (P=.005). CONCLUSIONS: Nonsmoking employees left unprotected from workplace secondhand smoke exposure had elevated levels of a tobacco-specific carcinogen in their bodies. All workers--including bar and restaurant workers--should be protected from indoor workplace exposure to cancer-causing secondhand smoke.

Is a statewide tobacco quitline an appropriate service for specific populations?

OBJECTIVE: To assess whether smoking quit rates and satisfaction with the Washington State tobacco quitline (QL) services varied by race/ethnicity, socioeconomic status, area of residence (that is, urban versus non-urban), or sex of Washington QL callers. METHODS: From October 2004 into October 2005, we conducted telephone surveys of Washington QL callers about three months after their initial call to the QL. Analyses compared 7-day quit rates and satisfaction measures by race/ethnicity, education level, area of residence and sex (using alpha = 0.05). RESULTS: We surveyed half (n = 1312) of the 2638 adult smokers we attempted to contact. The 7-day quit rate among survey participants at the 3-month follow-up was 31% (CI: 27.1% to 34.2%), 92% (CI: 89.9% to 94.1%) were somewhat/very satisfied overall with the QL programme, 97% (CI: 95.5% to 98.2%) indicated that they would probably/for sure suggest the QL to others and 95% (CI: 92.9% to 96.4%) were somewhat/very satisfied with the QL specialist. Quit rate did not vary significantly by race/ethnicity, education level, area of residence or sex. Satisfaction levels were high across subpopulations. Almost all participants (99%) agreed that they were always treated respectfully during interactions with QL staff. CONCLUSIONS: The Washington QL appeared effective and well received by callers from the specific populations studied. States choosing to promote their QL more aggressively should feel confident that a tobacco QL can be an effective and well received cessation service for smokers who call from a broad range of communities.

Five-year prospective prediction of self-initiated quitting of cigarette smoking of high-risk youth.

This paper provides a 5-year replication-extension of a previous 1-year follow-up study of the same sample of southern California alternative high school youth. Demographic, behavioral, psychosocial, and emerging adult function predictors of adolescent self-initiated smoking cessation were investigated. Based on the first (1-year) prospective study and this follow-up, one may speculate that smoking cessation programs for adolescents should include counteraction of problem-prone attitudes, assistance with job aspirations and information about drug-free workplaces, motivation to quit strategies, and assistance with overcoming withdrawal symptoms.

Six-month and one-year effects of project EX-4: a classroom-based smoking prevention and cessation intervention program.

OBJECTIVE: This study evaluated the efficacy of a version of Project EX that was adapted for implementation in the classroom context (Project EX-4). This paper reports the program outcomes based on pretest, six-month, and one-year follow-up surveys. METHODS: An 8 session classroom-based curriculum was tested with a clustered randomized controlled trial that involved a total of 1097 students in 6 program and 6 control alternative high schools. Weekly and monthly smoking was assessed at the three time points. Outcome effects were analyzed with multi-level random coefficients models. RESULTS: Students in the program condition experienced a greater reduction in weekly smoking and monthly smoking, at 6-and-12-month follow-ups. The net change varied between -5.1% and -7.6%, comparing the program condition to the control condition. CONCLUSIONS: The implementation of Project EX in a classroom setting produced decreases in smoking among students in the program, relative to those in the standard care control condition. It is likely that a classroom-based smoking prevention/cessation program can lead to lower overall smoking prevalence than a cessation program that is implemented in a school-based smoking cessation clinic format.

Short-term effects of Project EX-4: a classroom-based smoking prevention and cessation intervention program.

OBJECTIVE: Researchers continue to try to develop effective teen tobacco use prevention and cessation programs. Three previous school clinic-based studies established the efficacy of Project EX for teen smoking cessation. This fourth study adapts Project EX to the classroom context. This paper reports the findings based on pretest and posttest surveys conducted immediately prior and post-intervention. METHODS: An eight-session classroom-based curriculum was developed and tested with a randomized controlled trial that involved a total of 1097 students in six program and six control continuation high schools. Program-specific knowledge and smoking measures were assessed at both the pretest and posttest surveys, and were used to evaluate the program's effect on the immediate outcomes. The immediate outcomes effects were analyzed with multi-level random coefficients models. RESULTS: Program students provided favorable process ratings of the overall program and each session. Compared with the students in the control condition, students in the program condition showed a greater change in correct knowledge responses from pretest to posttest (beta=+5.5%, p=0.0003). Students in the program condition also experienced a greater reduction in weekly smoking (beta=-6.9%, p=0.038), and intention for smoking in the next 12 months (beta=-0.21 in 5-level scale, p=0.023). CONCLUSIONS: EX-4 immediate outcome results revealed favorable student responses to the program, increases in knowledge, and decreases in smoking relative to a standard care control condition.

A meta-analysis of teen cigarette smoking cessation.

OBJECTIVE: This article presents a meta-analysis of 48 teen cigarette smoking cessation studies, the 1st meta-analysis of its kind. The authors conducted searches of electronic databases and unpublished manuscripts from 1970 to 2003. Fifty contextual elements were coded from each article. A weighted least squares random effects method was used to pool results from individual study net effects estimates. Multilevel random coefficients modeling was applied to control for the intrastudy variation. MAIN OUTCOME MEASURES: The primary outcome for the present analysis was quit rate. Data were entered as intent-to-treat (ITT) quit rates (not compliance sample rates). Overall treatment effect size and treatment effect sizes as a function of program content, modality, number of sessions, and length of follow-up were examined. RESULTS: Across studies, program conditions, compared with control conditions, appeared to give smokers a 2.90% (95% confidence interval = 1.47-4.35%) absolute advantage in quitting, increasing the probability of quitting by approximately 46% (9.14% vs. 6.24%). Relatively higher quit rates were found in programs that included a motivation enhancement component, cognitive-behavioral techniques, and social influence approaches. Also, relatively higher quit rates were found in school-based clinic and classroom modalities. Furthermore, relatively higher quit rates were found for programs consisting of at least 5 quit sessions. Data also indicated that the effects were maintained at short-term (1 year or less) and longer term (longer than 1 year) follow-ups. CONCLUSION: Much more teen smoking cessation research is needed, but teen smoking cessation programming is effective, and the present study provides a framework to move forward.

The protective influence of spirituality and "Health-as-a-Value" against monthly substance use among adolescents varying in risk.

PURPOSE: To investigate the influence of two potentially protective factors, Health-as-a-Value and spirituality, on monthly alcohol, cigarette, and marijuana use in two multiethnic groups of adolescents varying in risk. METHODS: Three-hundred-eighty-two students from continuation/alternative high school, a population considered at risk for drug use, participated in the study. The other sample of 260 students was drawn from a medical magnet high school, and is considered to be at lower risk. Similar surveys containing measures of spirituality, "Health-as-a-Value," and monthly substance use, were distributed. Logistic regression analyses were performed. RESULTS: The analyses revealed that spirituality was protective against monthly alcohol use and marijuana use in the lower risk sample. In the higher risk sample, spirituality was protective against all monthly use. "Health-as-a-Value" (HAV) was protective against monthly alcohol use in the low risk sample, and protective against all monthly use in the higher risk sample. Importantly, when both constructs were entered into the same model, spirituality and HAV were independently protective of all monthly use for the higher risk sample and of monthly alcohol use in the lower risk sample. CONCLUSIONS: These findings extend earlier work on protective factors. "Health-as-a-Value" and spirituality may be protective against substance use in environments with different levels of use. Future studies should explore these findings in longitudinal analyses.

Five-year prospective prediction of marijuana use cessation of youth at continuation high schools.

This paper reports the prediction of marijuana use cessation among young adults who were regular users 5 years earlier. Social, attitude, intrapersonal, violence-related, drug use, and demographic baseline measures served as predictors of whether or not 339 teenage marijuana users reported having quit use 5 years later. Young adult social role variables were included as additional predictors. Quitting was defined as having not used marijuana in the last 30 days (42% of the sample at follow-up). After controlling for covariation among predictors, in a three-step analysis, only baseline level of marijuana use, male gender, young adult marital status, and friends' marijuana use (marginal) remained statistically direct predictors. Implications of these results include the need to reduce psychological dependence on marijuana and increase social unacceptability of marijuana use across genders to help increase prevalence of quit attempts.

Interpersonal conflict tactics and substance use among high-risk adolescents.

Adolescents who use aggressive tactics to handle interpersonal conflicts may be at high risk for substance use, while adolescents who possess coping strategies to avoid or manage interpersonal conflict may be at lower risk for substance use. This study examined the association between interpersonal conflict tactics and substance use among 631 continuation high school students. Items from a modified Conflict Tactics Scale formed three factors: Physical Aggression, Nonphysical Aggression, and Nonaggression. Logistic regression analyses revealed that adolescents' ways of responding to interpersonal conflicts were associated with their substance use. Use of physical aggression was associated with a higher risk of cigarette, alcohol, marijuana, and other drug use. Use of nonphysical aggression was associated with a higher risk of cigarette and alcohol use. Use of nonaggressive conflict tactics was associated with a lower risk of cigarette use. Adolescents who respond to interpersonal conflicts in an aggressive manner, whether physical or verbal/psychological, may be at increased risk for substance use, while nonaggressive conflict management skills may be protective. Possibly, teaching adolescents nonaggressive techniques for handling interpersonal conflict may be a useful strategy for preventing both interpersonal violence and substance use.

The associations of social self-control, personality disorders, and demographics with drug use among high-risk youth.

A 10-item self-report measure of social self-control was examined for its association with substance use, controlling for its associations with 12 personality disorder indices and 4 demographic variables among a sample of 1050 high-risk youth. Social self-control was found to be associated with 30-day cigarette smoking, alcohol use, marijuana use, and hard drug use, controlling for these other variables. The most consistent concurrent predictors of substance use were male gender, antisocial personality disorder, and social self-control. These results highlight the importance of social self-control as a unique concurrent predictor of substance use and suggest that social self-control skill training is relevant in substance abuse prevention programming.

Self-generated alcohol outcomes in 8th and 10th graders: exposure to vicarious sources of alcohol information.

The perceived positive and negative outcomes of alcohol use were studied in a sample of normal 8th and 10th grade students. Participants' responses provided associative frequency norms valuable for future research. Regression analyses showed (1) none of the individual-difference variables (alcohol use, exposure to vicarious sources of alcohol information, such as televised advertising, and demographics) predicted self-generated responses, and (2) alcohol use and first-hand observation of others' drinking did predict the valence respondents assigned to the outcomes. Results support and extend the findings of Stacy, Galaif, Sussman, and Dent [Psychology of Addictive Behaviors 10(1) 1996 18], wherein self-generated drug use outcomes appeared to be available in memory regardless of previous drug use or other individual differences.

Drug abuse prevention program development. Results among Latino and non-Latino white adolescents.

Five program development studies from Project Towards No Drug Abuse (TND) were re-analyzed to discern Latino versus non-Latino Whites similarities and differences in receptivity to a wide variety of high school-based drug abuse prevention activities. In most of the program development studies, these youth attended alternative (continuation) high schools in Southern California. Although there were a total of 46% Latino students in these schools, 99% of the students indicated English as the main language spoken at school and home. Thus, taken together, almost all Latino youth in the various studies analyzed preferred to respond to survey questions in English. Latinos were relatively low in socioeconomic status (SES) and used drugs less frequently. Still, this group of highly acculturated Latinos and non-Latino Whites (37% of the school population) perceived that they were attending alternative schools for the same reasons (e.g., lack of credits, truancy). Very few differences in receptivity ratings of proposed TND activities were found as a function of ethnicity. In other words, the data suggest that the same types of lessons are applicable to older teens in both ethnic groups.

Tracking procedures for locating high-risk youth.

Few published works are available that provide a comprehensive description of tracking procedures. This article describes the data collection tracking protocol that was used in Project Towards No Drug Abuse (Project TND), to follow high-risk youth over a 5 1/2 year period. Youth were followed from 1994 through 2000. A total of 35% of these youth were assessed 5 1/2 years later. Collapsing across the last two waves, 46% of these youth were followed an average of 5 years later. These procedures may be helpful in tracking highly mobile youth.

Project towards no drug abuse: a review of the findings and future directions.

OBJECTIVE: To provide a review of the evidence from 3 experimental trials of Project Towards No Drug Abuse (TND), a senior-high-school-based drug abuse prevention program. METHODS: Theoretical concepts, subjects, designs, hypotheses, findings, and conclusions of these trials are presented. A total of 2,468 high school youth from 42 schools in southern California were surveyed. RESULTS: The Project TND curriculum shows reductions in the use of cigarettes, alcohol, marijuana, hard drugs, weapon carrying, and victimization. Most of these results were replicated across the 3 trials. CONCLUSION: Project TND is an effective drug and violence prevention program for older teens, at least for one-year follow-up.

Influence of a substance-abuse-prevention curriculum on violence-related behavior.

OBJECTIVE: To test the impact of a school-based substance-abuse-prevention program, Project Towards No Drug Abuse (TND), on risk for violence. METHODS: Logistic regression analyses tested whether victimization, perpetration, or weapon carrying differed for intervention students relative to control students within a sample of 850 continuation high school students followed over 12 months. RESULTS: We observed a higher risk for victimization (OR=1.57) among male control students. No intervention effect was observed for female students or for perpetration among males. CONCLUSION: The findings provide limited support for a generalization of TND's preventive effect.

Prediction of violence perpetration among high-risk youth.

OBJECTIVES: To prospectively examine demographic background, personality, perceived environment, and behavior as violence perpetration predictors in emerging adulthood among high-risk adolescents using problem-behavior theory as a conceptual perspective. METHODS: Self-report questionnaires were administered 5 years apart to 676 participants. RESULTS: Hard drug use, belief that hurting another's property while drunk was acceptable, and high-risk group self-identification predicted later violence perpetration independent of baseline violence perpetration. CONCLUSIONS: Consistent with problem-behavior theory, personality, perceived environment, and behavior variables, beyond baseline violent behavior, predict risk for future violence perpetration in emerging adulthood, whereas demographic background may exert indirect effects.

Exposure to televised alcohol ads and subsequent adolescent alcohol use.

OBJECTIVE: To assess the impact of televised alcohol commercials on adolescents' alcohol use. METHODS: Adolescents completed questionnaires about alcohol commercials and alcohol use in a prospective study. RESULTS: A one standard deviation increase in viewing television programs containing alcohol commercials in seventh grade was associated with an excess risk of beer use (44%), wine/liquor use (34%), and 3-drink episodes (26%) in eighth grade. The strength of associations varied across exposure measures and was most consistent for beer. CONCLUSIONS: Although replication is warranted, results showed that exposure was associated with an increased risk of subsequent beer consumption and possibly other consumption variables.